Jesse D. Kosiba

Acute analgesic effects of nicotine and tobacco in humans: A meta-analysis

Abstract Although animal models have consistently demonstrated acute pain inhibitory effects of nicotine and tobacco, human experimental studies have yielded mixed results. The main goal of this meta-analysis was to quantify the effects of nicotine/tobacco administration on human experimental pain threshold and tolerance ratings. A search of PubMed and PsycINFO online databases identified 13 eligible articles, including k = 21 tests of pain tolerance (N = 393) and k = 15 tests of pain threshold (N = 339). Meta-analytic integration for both threshold and tolerance outcomes revealed that nicotine administered through tobacco smoke and other delivery systems (eg, patch, nasal spray) produced acute analgesic effects that may be characterized as small to medium in magnitude (Hedges g = 0.35, 95% confidence interval = 0.21-0.50). Publication bias-corrected estimates remained significant and indicated that these effects may be closer to small. Sex composition was observed to be a significant moderator, such that pain threshold effects were more robust among samples that included more men than women. These results help to clarify a mixed literature and may ultimately help to inform the treatment of both pain and nicotine dependence. Pain and tobacco smoking are both highly prevalent and comorbid conditions. Current smoking has been associated with more severe chronic pain and physical impairment. Acute nicotine-induced analgesia could make smoking more rewarding and harder to give up. Future research should use dynamic measures of experimental pain reactivity and further explore biopsychosocial mechanisms of action.

Relations between pain-related anxiety, tobacco dependence, and barriers to quitting among a community-based sample of daily smokers

There is increasing recognition that complex and potentially bidirectional relations between pain and smoking may be relevant to the maintenance of tobacco addiction. Pain-related anxiety has been identified as a mechanism in the onset and progression of painful disorders, and initial evidence indicates that pain-related anxiety may be associated with essential features of tobacco dependence among smokers with chronic pain. However, there has not been an empirical study of pain-related anxiety in relation to tobacco dependence and self-reported barriers to quitting among a community-based sample of daily smokers. The current sample was comprised of 122 daily smokers who were recruited from the local community to participate in a larger study that included an initial assessment of pain, smoking history, and pain-related anxiety. Approximately 17% of our sample endorsed moderate or severe past-month pain, nearly half met criteria for current anxiety or mood disorder, and about 30% met criteria for a current substance use disorder, exclusive of tobacco dependence. Results indicated that pain-related anxiety was uniquely and positively associated with both tobacco dependence severity scores and self-reported barriers to quitting. These findings lend support to the notion that pain-related anxiety may contribute to the maintenance of tobacco addiction among smokers who experience varying levels of pain severity.

A Pilot Study of Pain-Related Anxiety and Smoking-Dependence Motives Among Persons With Chronic Pain

Complex interactions between pain and tobacco smoking have been of increasing interest to researchers and clinicians from a variety of disciplines. There is also recent evidence to suggest that pain-related anxiety may play an important role in the maintenance of tobacco dependence among persons with comorbid pain disorders. The goal of the current study was to evaluate the explanatory relevance of pain-related anxiety in relation to tobacco dependence among a sample of daily smokers with current chronic pain. Participants were recruited from the general population to complete an online survey that was developed to examine interrelations between chronic pain and tobacco smoking. Fifty-six of 129 (43%) daily smoking respondents met criteria for current chronic pain. Results indicated that pain-related anxiety accounted for a significant portion of the unique variance in total smoking dependence scores, and both primary and secondary dependence composite scores (as measured by the Wisconsin Inventory of Smoking Dependence Motives; Piper et al., 2004). It is noteworthy that these effects were observed above and beyond the variance accounted for by relevant sociodemographic factors, generalized anxiety, and pain severity. Pain-related anxiety was observed to be strongly associated with secondary dependence motives, which is consistent with a conceptualization of pain-related anxiety as an instrumental or situational motivator of smoking. These results suggest that tobacco smokers with comorbid pain disorders may be at risk for maintaining or exacerbating their dependence on tobacco, possibly due to individual differences in pain-related anxiety. These findings may help inform the development of tailored interventions for smokers with comorbid chronic pain.

Chronic Pain Status, Nicotine Withdrawal, and Expectancies for Smoking Cessation Among Lighter Smokers.

BackgroundChronic pain and tobacco smoking are both highly prevalent and comorbid conditions, and chronic pain may pose a barrier to smoking cessation.PurposeThe objective of this study was to test associations between chronic pain status and several smoking-related factors that have previously been shown to predict cessation outcomes.MethodDaily smokers (N = 205) were recruited from the general population to complete an online survey of pain and tobacco smoking.ResultsResults indicated that smokers with chronic pain (vs. no chronic pain) consumed more cigarettes per day, scored higher on an established measure of tobacco dependence, reported having less confidence in their ability to quit, and endorsed expectations for experiencing greater difficulty and more severe nicotine withdrawal during future cessation attempts. Mediation analyses further indicated that the inverse association between chronic pain and abstinence self-efficacy was indirectly influenced by past cessation failures.ConclusionsThese findings suggest that individuals with chronic pain may constitute an important subgroup of tobacco smokers who tend to experience lower confidence and greater difficulty when attempting to quit. Future research would benefit from replicating these findings among older and more diverse samples of heavier tobacco smokers, and extending this work to the study of prospective relations between chronic pain status and cessation-relevant processes/outcomes over the course of a quit attempt.

Chronic Pain and Marijuana Use among a Nationally Representative Sample of Adults

This study sought to examine the relations between chronic pain and marijuana use in a large nationally representative survey of adults (n = 5,672; 53% female; M(age) = 45.05, SD = 17.9) conducted in the United States. After controlling for sociodemographic variables, lifetime history of depression, and alcohol abuse/dependence, there was a significant association between lifetime chronic pain and lifetime and current marijuana use. Moreover, current chronic pain was significantly associated with lifetime marijuana use. There was no significant association between current chronic pain and current marijuana use, possibly owing to limited statistical power. Results suggest that there are generally consistent statistically significant relations between chronic pain and marijuana use. Future work is needed to explicate the developmental patterning between chronic pain and marijuana use. This paper presents the potential linkage between chronic pain and marijuana use. Results from this study suggest that it may be beneficial for clinicians to assess for marijuana use among patients suffering from chronic pain. Such patients may be using marijuana as a maladaptive coping strategy.

Associations between Pain Intensity and Urge to Smoke: Testing the Role of Negative Affect and Pain Catastrophizing

BACKGROUND Cigarette smokers are more likely to experience pain than nonsmokers, and experimental research indicates that pain is a potent motivator of smoking. Urge to smoke is a predictor of early relapse, yet associations between pain and urge to smoke have yet to be tested among daily smokers. This study aimed to conduct the first crosssectional test of associations between current pain intensity and urge to smoke, and to test the role of negative affect and pain catastrophizing in relations between pain intensity and urge to smoke. METHODS Participants (N = 229, 42.4% Female, 38.9% black/African American, Mcpd = 21.9) were recruited for a laboratory study of pain and smoking, and these data were collected at the baseline session. Data were analyzed using a series of regressions and conditional process models. RESULTS Current pain intensity was positively associated with urge to smoke, and urge to smoke for the relief of negative affect. There was an indirect association via state negative affect, such that pain intensity was positively associated with negative affect, which in turn was associated with greater urge to smoke. Further, positive associations between pain intensity and urge to smoke were only evident among smokers who endorsed low (vs high) levels of catastrophizing. CONCLUSIONS These findings contribute to an emerging literature indicating that pain and related constructs are relevant to the maintenance of tobacco smoking. Future research should examine how painrelevant cognitive-affective factors may influence associations between the experience of pain and motivation to smoke tobacco.

Nicotine deprivation increases pain intensity, neurogenic inflammation, and mechanical hyperalgesia among daily tobacco smokers.

An evolving reciprocal model posits that pain and tobacco smoking behavior interact in the manner of a positive feedback loop, resulting in greater pain and the maintenance of nicotine dependence. There is also reason to believe that abstaining from smoking may increase pain during the early stages of smoking cessation. The goal of this study was to test the effects of nicotine deprivation on experimental pain reactivity. Daily tobacco cigarette smokers (N = 165; 43% female) were randomized to either extended nicotine deprivation (12–24 hr smoking abstinence), minimal deprivation (2 hr smoking abstinence), or continued smoking conditions, prior to undergoing pain induction via topical capsaicin. As hypothesized, results indicated that extended deprivation (relative to continued smoking) increased capsaicin-induced pain intensity ratings, neurogenic inflammation, and mechanical hyperalgesia, thus implicating both central and peripheral mechanisms of action in the effects of smoking abstinence on pain reactivity. Pain intensity ratings were also positively correlated with nicotine withdrawal symptoms, and exploratory analyses suggest that pain sensitivity may increase with duration of smoking abstinence. Collectively, these findings indicate that smokers may experience a variety of negative pain-related sequelae during the early stages of a quit attempt. Future research should examine pain as a consequence or correlate of the nicotine withdrawal syndrome, and determine whether smokers may benefit from tailored cessation interventions that account for nicotine deprivation-induced amplification of pain.

Suicide risk among Veteran primary care patients with current anxiety symptoms

Background Although anxiety is prevalent in primary care, the association between anxiety symptoms and suicide risk remains understudied. Objectives This cross-sectional study aimed to (i) assess the prevalence of suicide risk among Veteran primary care patients with anxiety symptoms and (ii) compare suicide risk between patients with a positive (versus negative) depression screen. Methods Participants were 182 adult primary care patients (84.6% male, Mage = 58.3 years) with current anxiety symptoms, but no psychotherapy in specialty care in the past year, at a Veterans Health Administration medical center in New York. Participants completed self-report measures of anxiety, depression and suicide risk via telephone. Results Forty percent endorsed ≥1 suicide risk item. Suicide risk was more common among those screening positive (versus negative) for depression (50.5% versus 26.5%, χ2 (1) = 10.88; P = 0.001). Participants with a negative depression screen constituted 31% of all those with any suicide risk. Logistic regression revealed that anxiety symptom severity was not associated with suicide risk (P = 0.14) after controlling for age, sex and depression screen status (P = 0.01). Conclusions A substantial proportion of primary care patients with anxiety was classified as at risk for suicide, even in the absence of a positive depression screen. Primary care providers should assess suicide risk among patients with anxiety symptoms, even if the patients are not seeking specialty mental health treatment, the anxiety symptoms are not severe or do not rise to the level of an anxiety disorder, and comorbid depressive symptoms are not present.

Effects of nicotine deprivation on current pain intensity among daily cigarette smokers.

Animal research has consistently demonstrated increased pain in the context of nicotine deprivation, and there is cross-sectional evidence that tobacco smokers may experience greater pain following periods of smoking abstinence. This study aimed to examine current pain intensity as a function of nicotine deprivation among 137 daily tobacco smokers who did not endorse chronic pain and were recruited to participate in a primary study of the effects of smoking abstinence on experimental pain reactivity. Participants were randomized to either deprivation (12–24 hr abstinence) or continued ad lib smoking conditions. Compliance with the manipulation was biochemically verified via expired carbon monoxide (CO). Current pain intensity was assessed at baseline (Session 1) and following the deprivation manipulation (Session 2) using a single item that asked participants to indicate their current level of pain on a scale ranging from 0 (no pain) to 10 (pain as bad as you can imagine). At baseline, the majority of participants (51.1%) reported no pain (M = 1.75). As hypothesized, participants randomized to nicotine deprivation (vs. continued smoking) reported greater current pain intensity following the manipulation. Among smokers who reported no pain at baseline, those who abstained from smoking were nearly 3.5 times more likely to endorse pain at Session 2. These results suggest that daily tobacco smokers may experience greater pain during the first 12–24 hr of smoking abstinence. Future research should examine the role of pain in nicotine withdrawal, and whether tailored interventions may be needed to account for nicotine deprivation-induced amplification of pain.

A qualitative study of the feasibility and acceptability of a smoking cessation program for people living with HIV and emotional dysregulation

ABSTRACT Despite high rates of co-occurring tobacco use and anxiety among persons living with HIV, evidence-based interventions for these individuals are limited. An existing cognitive–behavioral treatment protocol for smoking cessation and anxiety (Norton, P. J., & Barrera, T. L. (2012). Transdiagnostic versus diagnosis-specific CBT for anxiety disorders: A preliminary randomized controlled noninferiority trial. Depression and Anxiety, 29(10), 874–882. https://doi.org/10.1002/da.21974) was modified to address transdiagnostic constructs, such as anxiety sensitivity, distress tolerance, and depressive symptomatology (Labbe, A. K., Wilner, J. G., Kosiba, J. D., Gonzalez, A., Smits, J. A., Zvolensky, M. J., … O’Cleirigh, C. (2017). Demonstration of an Integrated Treatment for Smoking Cessation and Anxiety Symptoms in People with HIV: A Clinical Case Study. Cognitive and Behavioral Practice, 24(2), 200–214. https://doi.org/10.1016/j.cbpra.2016.03.009). This study examines the feasibility and acceptability of the intervention as determined from qualitative data from structured exit interviews from 10 participants who completed treatment. Results demonstrated that participants were very motivated to quit smoking and enrolled in the program for health-related reasons and to be able to quit. Participants found nearly all the treatment components to be useful for reaching their smoking cessation goal and in managing emotional dysregulation. Last, all participants stated that they would strongly recommend the treatment program. This qualitative study provides initial evidence for the feasibility and acceptability of a modified smoking cessation treatment protocol for HIV+ individuals with anxiety and emotional dysregulation. Future research will focus on evaluating the efficacy of the protocol in a full-scale randomized controlled trial, as well as working to collect qualitative data from participants who discontinue treatment to better understand reasons for treatment attrition.